Can someone help me with this issue? We have a surgery scheduled for debridement of sternum, which is an either/or procedure…. Physician does more and goes into the bone and now it is on the inpatient only list. We had them as an outpatient. How do other hospitals get it right? The coders don’t have the op note until the patient has been discharged. Any suggestions??

Looking for feedback on elderly patients who fall and have a nondisplaced pelvic fracture not requiring surgery. Physical Therapy evaluates the patient and recommends rehab, yet they are only on oral pain medications. Are they acute or observation status? What if the the patient is not safe for discharge to home? What is the recommended status?

Along with my case question below can any of you tell me if you are giving discharge folders to your patients? If you do this, what is included in the folder? This is a practice that I would like to initiate but would like some input first.
Thanks,

The longer I do this job, the less I understand it! Is anyone willing to share how they change the status order when it is put in wrong on a previous day for Medicare Advantage plans? i.e. doc writes an OBS order then case manager reviews case the next day and it qualifies for InPatient. What do you do after discharge? I understand I cannot back date or write a retro order on a straight Medicare patient. Thanks again!

A Medicare patient was admitted without any admit order and later discharged to a nursing home. After the patient was there it was discovered that there was not an admit order on the chart and so an inpatient admit order was documented days after the discharge. I am wondering if this is appropriate. Are not all patients in Medicare’s eyes considered inpatient unless otherwise specified?

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